Post on 26-Feb-2018
Functional Capacity Evaluation (FCE) / Physical Performance Test (PPT) Summary Report
Examinee #
Examinee: Test Date: Occupation: Date of Birth: Date of Injury: ICD-9 Codes: 1. 2. 3. 4.
Hand Grip Strength Protocol (Standard Protocol, 5 positions, bell curve strength re
Right Hand: out of 5 valid, Bell Curve, Yes No
liability test):
Left Hand: out of 5 valid, Bell Curve, Yes No Cross Validation Strength Grip Protocol (Rapid Exchange, 1 position reliability test)
Static Strength/ Reliability Protocol Vertical Height Avg. Amount Demonstrated Reliable High Near lift (0-60 in.) lbs. Yes No Arm Lift ( 32-60 in.) lbs. Yes No Leg Lift (0-32 in.) lbs. Yes No
Dynamic Lifting Capacity Frequent Lift Occasional Lift Vertical Height Max. Lifted Reliable Max. Lifted Reliable Floor to shoulder ( 60 in) lbs Yes No lbs Yes No Knuckle to Shoulder ( 32-60) lbs Yes No lbs Yes No Floor to Knuckle (0-32) lbs Yes No lbs Yes No
Vocational Implication Examinee qualifies for the work category. to lbs. Max. Occasionally to lbs. Max. Frequently
Interpretation Physical Effort: Cooperation: Symptom mgmt. Control: Body Mechanics:
Functional Activities Maximum lbs. Carry Cycles* Reliable Carrying lbs. (Heaviest) # of cycles Yes No Cardio Respiratory Protocol VO2 Submaximal Heart Rate VO2 Fitness Classification: ml/kg/min Start Stop Cardio Fitness Test: *1cycle = 50 ft.
Total Evaluation Time Start Time: Stop Time: Total Hrs: Requesting Doctor:
Comments:
Authorizing Physician: Physicians Name::
SAMPLE SUMMARY REPORT
Functional Capacity Report
Patient: David Patient SSN: 123-45-6789 DOI: 01/05/09 Dear Dr. Good, David Patient was seen for an FCE on Tuesday, May 7, 2009. Mr. Patient’s range of motion was within functional to normal range with the following exceptions: Right knee flexion 117 degrees (78% of normal*). Right ankle plantarflexion 33 degrees (82% of normal), eversion 16 degrees (80% of normal). Right shoulder flexion 124 degrees (83% of normal), extension 32 degrees (80% of normal) Abduction 107 degrees (71% of normal), internal rotation 60 degrees (75% of normal). True lumbar flexion 50.0 degrees (83% of normal), left straight leg raise 35.7 degrees (45% of normal), right straight leg raise 37% of normal). On the Bruce Treadmill Test, the patient completed a three minute cycle at speeds of 1.7 mph and 2.5 mph. He voluntarily stopped the test at 34 seconds into the third cycle at 3.4 mph, complaining of right ankle pain. His heart rate increased from 88bpm to 114bpm. His VO2 max corresponds to the 0 (zero) percentile and is a poor ranking. On the Jamar hand dynamometer, he did show a bell-shaped curve and a particular difference between the 2 hands, which may be indicative of maximal effort. His coefficient of variation was below the acceptable maximum of 15% in 10 out of 10 trials, which indicates consistent effort. He demonstrated a negative rapid exchange grip, which may be an indicator of maximal effort. On the strength testing and standard NIOSH, COV for static push, static arm lift, static leg lift, and static high near lift were all less than the acceptable maximum of 15%, which may be an indicator of consistent effort. On dynamic lifting floor-to-waist, floor to shoulder, and waist to shoulder, Mr. Patient completed one cycle each of 10, 20, and 30 lbs. On dynamic carrying he was able to complete one cycle each of 10, 20, 30, and 40 lbs. He complained of right ankle, right shoulder, and lumbar pain during these activities, reporting an increase from a pain level of 4/10 to 5/10. His beginning heart rate was 88bpm, and his maximum heart rate was 102bpm. He did not reach his projected rate of 161bpm. If I can supply further information or clarify this data, please feel free to contact me. Sincerely, Patricia Ellison, OTR *100% = normal (Reference Information: American Medical Association Guidelines, Guides to the Evaluation of Permanent Impairment, Fifth Edition)
Functional Capacity Evaluation
Client Name:
Date of Birth:
Injury Date:
Dominant Hand:
Start & Finish Date:
Mr. David Patient
September 29, 1977
January 05, 2009
Right Hand
May 07, 2009
PREPARED FOR:
Gender: Male
Client Information
Clinic File #:6354
Height: 67 inchesWeight: 200 lbs
Occupation: Driver
Work Status:
Employer:Address:
Currently working
MVT Services LLC DBA 350 Picacho AveLas Cruses, N.M.85017
Employment Information
Address: P.O. Box 2338Chandler, OK74835(800) 338-2510
Insurance InformationCompany: National American State
SSN: 635-24-7654
Address: 1708 N. Estrella StEl Paso, TX79902
Attn: Dr. Feel Good2995 LBJ Freeway Suite#14Dallas, TX75234Tel: (972) 766-4515
Areas of Complaint
Shoulder
Ankle
Lumbar
Knee
Specific Location Plane Side Pain Type Pain ScaleGeneral Location
Tingling, PokingRightUnilateralAnkle 4 - Low Moderate
Throbbing, Aching,CenterPosterior Lumbar 4 - Low Moderate
Throbbing, Aching, Stabbing
RightUnilateralKnee 4 - Low Moderate
Tingling, PokingRightUnilateralShoulder 4 - Low Moderate
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
All testing was completed using the FOCUS System, Data Management was compiled through ODES products of BTE Technologies P. 1
P. 2 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
Flexion Extension
May 07, 2009
01170150
Knee - Right
Normals:
Range of Motion
78% 100%% of Normal
045
90
135180
American Medical Association Guides to the Evaluation of Permanent Impairment, Fifth EditionReference Information
Flexion Extension Abduction Adduction Internal Rotation External Rotation
May 07, 2009
40 150 30 77 9015040 150 30 80 90150
Shoulder - Left
Normals:
Range of Motion
100% 100% 100% 96% 100%100%% of Normal
04590
135180
American Medical Association Guides to the Evaluation of Permanent Impairment, Fifth EditionReference Information
Flexion Extension Abduction Adduction Internal Rotation External Rotation
May 07, 2009
32 107 30 60 8812440 150 30 80 90150
Shoulder - Right
Normals:
Range of Motion
83% 71% 100% 75% 98%80%% of Normal
045
90
135180
American Medical Association Guides to the Evaluation of Permanent Impairment, Fifth EditionReference Information
PATRICIA ELLISON3100 N. LEE TREVINO STE. B EL PASO TX 79936 (915) 590-7246
P. 3 Mr. David Patient
23 29 25 35 275123 27 25 35 2950
True Lumbar Flexion
True Lumbar Extension
Left Lateral Flexion
Right Lateral Flexion
Left Straight Leg Raise
Right Straight Leg Raise
May 07, 2009
Trial 1:
Trial 3:Trial 2:
22 25 25 37 324925 25 25 80 8060
Lumbar
Normals:
Range of Motion
50.0 22.7 27.0 25.0 35.7 29.351.0 23.0 29.0 25.0 37.0 32.0
83% 108% 100% 45% 37%91%
AverageMaximum
YES YES YES YES YES YESAMA Valid% of Normal
045
90
135180
Trial #1 2 3
Trial #1 2 3
Trial #1 2 3
Trial #1 2 3
Trial #1 2 3
Trial #1 2 3
American Medical Association Guides to the Evaluation of Permanent Impairment, Fifth EditionReference Information
Plantarflexion Dorsiflexion Inversion Eversion
May 07, 2009
20 30 163320 30 2040
Ankle - Right
Normals:
Range of Motion
82% 100% 80%100%% of Normal
045
90
135180
Trial #1 2 3
Trial #1 2 3
American Medical Association Guides to the Evaluation of Permanent Impairment, Fifth EditionReference Information
P. 4 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
Plantarflexion Dorsiflexion Inversion Eversion
May 07, 2009
20 30 204020 30 2040
Ankle - Left
Normals:
Range of Motion
100% 100% 100%100%% of Normal
045
90
135180
Trial #1 2 3
Trial #1 2 3
American Medical Association Guides to the Evaluation of Permanent Impairment, Fifth EditionReference Information
Flexion Extension
May 07, 2009
01330150
Knee - Left
Normals:
Range of Motion
89% 100%% of Normal
045
90
135180
Trial #1 2 3
Trial #1 2 3
American Medical Association Guides to the Evaluation of Permanent Impairment, Fifth EditionReference Information
P. 5 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
Hand Grip StrengthHand Grip Strength
The JAMAR hand dynamometer was used in order to quantify grip strength and determine whether Mr.Patient exerted consistent effort during grip strength testing. Mr. David Patient was tested using the maximum voluntary effort and rapid exchange hand grip protocols. Mr. David Patient is right hand dominant. Normative data is based on the assumption that right and left hand dominant subjects, analyzed separately show little functional difference between their mean scores.¹· ²·
010203040
50RightRight
Hand Grip Setting
Forc
e (lb
s)
1 2 3 4 5
Left Right
48.9 lbs.
44.2 lbs.52.5 lbs.52.2 lbs.
38.2 lbs.Pos #4Pos #5
Pos #1Pos #2Pos #3
0
13
26
39
53LeftLeft
Hand Grip Setting
Forc
e (lb
s)
1 2 3 4 5
Maximum Voluntary Effort (MVE)
45.4 lbs.44.8 lbs.
40.0 lbs.48.3 lbs.
34.2 lbs.
Using the Maximum Voluntary Effort (MVE) protocol over a range of five positions on the hand dynamometer, it is expected that the strength graphs obtained results in a bell-shaped curve³·¹¹·¹²·¹³· even in a disabled population or if the client's hand is injured³· ¹³· with at least 6 of the 10 coefficients of variation within the acceptable 15% or less limit.²²
The graph obtained for Mr. David Patient did demonstrate a bell shaped curve which may be an indicator of maximal effort and the coefficients of variation of the underlying data may be an indicator of consistent effort with all 10 coefficients of variation within the 15% acceptable limit.
The hand dynamometer is set to each of the five available
positions which vary the client's grip size. The results
for each of the average maximum forces during each position are displayed by the
corresponding bar graphs.
May 07, 2009
3.3%2.4%
5.1%2.4%
4.7%
5.5%2.3%
10.9%1.5%
6.0%
COV COV
St. Dev. 5.4 Lbs. 4.9 Lbs.
09
18
2736
45
54LeftLeft
Time (s)
Forc
e (lb
s)
0
10
20
30
40
50RightRight
Time (s)
Forc
e (lb
s)
Rapid Exchange Grip (REG)
Average 47.1 lbs.
48.2 lbs.
45.4 lbs.
Diff L Vs. R 3.8%
42.4 lbs.47.0 lbs.54.1 lbs.
39.7 lbs.43.8 lbs.
Maximum 54.1 lbs. 48.2 lbs.
Trial #1
Trial #2Trial #3
1 1
Left Right
0.750.25 0.750.250 0
47.3 lbs.43.7 lbs.Trial #447.3 lbs.50.0 lbs.Trial #5
Trial #6 45.9 lbs.45.1 lbs.The hand dynamometer is set to position 2. The client
applies a maximum force for a one second trial duration quickly alternating between
hands. The average maximum force for all six trials is compared to the
maximum voluntary effort value in the same position for
reliability purposes.¹³
May 07, 2009
The peak average force value recorded during the maximum voluntary effort protocol was 52.5 lbs performed at position 2. The Rapid Exchange Grip (REG) protocol was therefore administered at this position. A negative rapid exchange grip (REG) occurs when the average of the values recorded during the rapid exchange grip protocol are less than the average of the values recorded during the maximum voluntary effort protocol in the same position and for the same hand. Conversely, a positive REG occurs when the average of the values recorded during the rapid exchange grip protocol exceed the average of the values recorded during the maximum voluntary effort protocol in the same position and for the same hand. A negative REG allows the evaluator to have more confidence that the evaluee is performing maximally. A positive REG may be an indicator of submaximal effort.¹³ Mr. David Patient produced an average value of 47.1 lbs for the left hand and 45.4 lbs for the right hand during the rapid exchange protocol. He produced an average value of 52.5 lbs for the left hand and 48.3 lbs for the right hand during the maximum voluntary effort protocol. David Patient therefore demonstrated a negative REG which may be an indicator of maximal effort.
³ Stokes H. 1983. The seriously uninjured hand - weakness of grip. J Occup Med 25(9):683-684.¹¹ Niebuhr B, Marion R. 1990. Voluntary control of submaximal grip strength. Am J Phys Med Rehabil 69(2): 96-101.¹² Matheson L, Carlton R, Niemeyer L. 1988. Grip strength in a disabled sample: reliability and normative standards. Ind Rehabil Q 1(3):9,17-23.¹³ Hildreth D, Breidenbach W, Lisiter G, Hodges A. 1989. Detection of submaximal effort by use of the rapid exchange grip. J Hand Surgery 14A(4): 742-745.²² Klimek E, Strait J. 1997. Volition in impairment rating: the validity of effort assessment. J Occup Med 6(2) 9-18.
P. 6 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
Pinch StrengthPinch Strength
The FOCUS pinch strength test is performed to quantify pinch strength as compared to population norms.† Mr. David Patient was asked to perform three forms of pinch strength tests including the tip, key and palmar pinch. The data demonstrated that Mr. David Patient's tip pinch strength was normal for both the left and right hand. His left hand was 15.9% stronger than the right hand. Key pinch strength was normal for both the left and right hand. His left hand was 14.9% stronger than the right hand. Palmar pinch strength was low for the left hand and significantly low for the right hand. His left hand was 19.4% stronger than the right hand.
0
10
20
30
40
50LeftLeft
For
ce (
lbs)
Normal RangeNormal Range
0
10
20
30
40
50RightRight
Time (s)
For
ce (
lbs)
Normal RangeNormal Range
Key Pinch Strength
Left Right
Average
Trial #1
Trial #2
Trial #3
26.5 lbs.
26.5 lbs.
23.1 lbs.
COV 10.4% 16.1%
Diff L Vs. R 14.9%
22.7 lbs.
29.2 lbs.
27.6 lbs.
17.9 lbs.
24.8 lbs.
Maximum 29.2 lbs. 26.5 lbs.
3321 210 0
Time (s)
The client squeezes the pinch gauge using a key pinch for a three second trial duration. A rest period of 5 seconds is
given before testing the other hand. This process is repeated three times. The
average of the three trials is compared to puplished
population normal values.†
May 07, 2009
0
10
20
30
40
50LeftLeft
Time (s)
For
ce (
lbs)
Normal RangeNormal Range
0
10
20
30
40
50RightRight
Time (s)
For
ce (
lbs)
Normal RangeNormal Range
Palmar Pinch Strength
Average 16.0 lbs.
13.9 lbs.
13.4 lbs.
COV 22.8% 2.7%
Diff L Vs. R 19.4%
11.0 lbs.
19.6 lbs.
17.4 lbs.
13.1 lbs.
13.2 lbs.
Maximum 19.6 lbs. 13.9 lbs.
Trial #1
Trial #2
Trial #3
3 3
Left Right
21 210 0
The client squeezes the pinch gauge using a palmar pinch for a three second trial duration. A rest period of 5
seconds is given before testing the other hand. This process is repeated
three times. The average of the three trials is compared
to puplished population normal values.†
0
10
20
30
40
50LeftLeft
Time (s)
For
ce (
lbs)
Normal RangeNormal Range
0
10
20
30
40
50RightRight
Time (s)
For
ce (
lbs)
Normal RangeNormal Range
Tip Strength
15.1 lbs.
13.2 lbs.
13.0 lbs.
13.5% 3.6%
15.9%
14.6 lbs.12.9 lbs.
17.8 lbs.
12.4 lbs.13.5 lbs.
17.8 lbs. 13.5 lbs.Average
COV
Diff L Vs. R
Maximum
Trial #1
Trial #2
Trial #3
3 3
Left Right
2121 00
The client squeezes the pinch gauge using a tip
pinch for a three second trial duration. A rest period of 5
seconds is given before testing the other hand. This process is repeated
three times. The average of the three trials is compared
to puplished population normal values.†
0.0
25.0
50.0
Pinch Strength Average Force ComparisonPinch Strength Average Force Comparison
For
ce (
lbs)
Tip Key Palmar
15.1 13.0
26.5 23.116.0 13.4
† Mathiowetz V, Kashman N, Volland G, Weber K, Dowe M, Rogers S. 1985. Grip and pinch strength: normative data for adults. Arch Phys Med
Left Hand(Average Force)
Right Hand (Average Force)
P. 7 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
Static Push Strength
Average:
May. 07, 2009
Force (lbs)
0.0
16.0
32.0
48.0
64.0
80.0
Time (s)
Stat
ic S
treng
th (l
bs)
0.0
16.0
32.0
48.0
64.0
80.0
Time (s)
Stat
ic S
treng
th (l
bs)
10/30Wide
COV:
Acc. Rot. Angle:Accessory Angle
Handle TypeFoot Placement
Mr. Patient reached an average peak force of 60.7 lbs. for the Static Push Strength test. The coefficient of variation was 7.7% during the Static Push Strength. Values greater than 15% may be an indicator of submaximal effort.
31.50
Test Date:
67.1 lbsTrial 1:58.9 lbsTrial 2:
Trial 3:56.0 lbs
0 1 2 3 4 525
64
103
142
181
220
Time (min)
BPM
During Test
44%
56%60.7 lbs7.7%
P. 8 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
Standard NIOSHStandard NIOSH
Mr. David Patient's ability to lift, push or pull was assessed using the FOCUS Standard NIOSH strength test. It is predictable that leg strength will be greater than either torso or arm strength.†
01020
304050
6070
Leg LiftLeg Lift
Forc
e (lb
s)
0
8
16
2432
40
48Arm LiftArm Lift
Forc
e (lb
s)
0
10
20
30
40
50 Torso LiftTorso Lift
Forc
e (lb
s)
0
9
18
27
36
45
54High Near LiftHigh Near Lift
Forc
e (lb
s)
5
5
5
5
2.5
2.5
2.5
2.5
0
0
0
0
An average force of 56.8 lbs. was exerted by Mr. David Patient during the leg lift. The coefficient of variation for this test was 4%. Values greater than 15% may be an indicator of inconsistent effort.
An average force of 40.1 lbs. was exerted by Mr.David Patient during the arm lift. The coefficient of variation for this test was 11%. Values greater than 15% may be an indicator of inconsistent effort.
An average force of 44.7 lbs. was exerted by Mr. David Patient during the high near lift. The coefficient of variation for this test was 9%. Values greater than 15% may be an indicator of inconsistent effort.
Throbbing to lumbar reported throughout activity. Poking/stabbing pain to right ankle reported during leg lift. Torso Lift not performed
Force
Average
Trial #1
Trial #2
Trial #3
COV
Maximum
Force
Average
Trial #1
Trial #2
Trial #3
COV
Maximum
Force
Average
Trial #1
Trial #2
Trial #3
COV
Maximum
Time (s)
† Atuahene, F and A. Freivalds (1987) Comparison of Dynamic Static and Psychophysical Evaluations of Human Strength Capablities. Journal of Human Ergology, Vol. 16, No. 2: 17-191
The client pulls up for a five second trial duration. A rest period of 15 seconds is given in between the three trials.
The client pulls up for a five second trial duration. A rest period of 15 seconds is given in between the three trials.
The client pulls up for a five second trial duration. A rest period of 15 seconds is given in between the three trials.
The client pushes up for a five second trial duration. A rest period of 15 seconds is given
in between the three trials.
Evaluator Comments
Time (s)
Time (s)
Time (s)
0 1 2 3 4 50
20
40
60
80
100
Hea
rt R
ate
(BPM
)
Peak:
Final:
0 1 2 3 4 50
20
40
60
80
100
Hea
rt Ra
te (B
PM)
0 1 2 3 4 50
20
40
60
80
100
Hea
rt R
ate
(BPM
)
0 1 2 3 4 50
20
40
60
80
100
Hea
rt Ra
te (B
PM)
During Prior/AfterMin:
Force
Average
Trial #1
Trial #2
Trial #3
COV
Maximum
Peak: Final:
During Prior/AfterMin:
Peak: Final:
During Prior/AfterMin:
Peak: Final:
During
Prior/AfterMin:
May 07, 2009
56.8 lbs.
04.0%
58.5 lbs.
58.0 lbs.
54.0 lbs.
58.5 lbs.
40.1 lbs.
11.0%
34.4 lbs.
45.3 lbs.
40.6 lbs.
45.3 lbs.
44.7 lbs.
09.0%
39.2 lbs.
48.4 lbs.
46.4 lbs.
48.4 lbs.
P. 9 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
30 lbs.
The Dynamic Lifting - Floor to Waist Occasional was conducted in Mr. Patient's case in order to determine his ability to complete the task. A progressive loading method was used to determine Mr. Patient's capacity for the performance of dynamic lifting activities on a safe and dependable basis. Lifting was conducted between waist height and floor height for a total of 1 repetition at each weight increment. The increase in the amount of weight lifted was in 10-pound increments.
In order to ensure safety in the administration of the testing protocol, Mr. Patient's heart rate was monitored on a real-time basis. A cut-off of 161 beats per minute, based upon 85 percent of the age-predictive maximum heart rate was used in order to ensure the safe administration of the dynamic lifting protocol. A rating of perceived exertion was also used in order to make certain Mr. Patient was capable of continuing in the protocol without risk of injury.
During the course of testing Mr. Patient's heart rate increased from 90 beats per minute to a peak of 98 beats per minute at the final weight of 30 lbs. This represented a heart rate increase of 9% during the lifting protocol. Mr. Patient's heart rate did not recover. Instead it remained constant at 98 beats per minute during the 1 minute recovery period.
Mr. Patient demonstrated a safe weight lifting ability of 30 lbs. The reason for the conclusion of the dynamic lifting protocol was the fact Mr. Patient stopped the test due to psychophysical factors.
0.0 0.3 0.6 0.9 1.2 1.5 1.8 2.1 2.4 2.7 3.00
44
88
132
176
220
Time (min)
Hea
rt R
ate
(BP
M) 90 BPM
98 BPM 98 BPM
98 BPM
Initial Heart Rate:Peak Heart Rate:
Final Testing Heart Rate:
Final RecoveryHeart Rate: 9 %% Heart Rate Increase:
98 BPMAvg. Recovery Heart Rate
01:3201:00
Elapsed Time:Recovery Time:During Testing Before & After Testing
Dynamic Lifting - Floor to Waist Occasional
Maximum Allowable HR--
Initial Weight
Starting HeightEnding Height
Waist HeightFloor Height10.0 lbs.
Weight Increments 10.0 lbs.Repetitions Per Weight 1 RepetitionRest Period Per Weight Cycle No Rest Period
Exertion Rating Stop PointHeart Rate Cut OffMaximum Test DurationMaximum Allowed Weight
Heavy85% of age adj.UnlimitedNone
Maximum Safe Weight Lifted
May 07, 2009
Patient reported pain to right ankle and lumbar region during this activity.Evaluator Comments
P. 10 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
30 lbs.
The Dynamic Lifting - Floor to Shoulder Occasional was conducted in Mr. Patient's case in order to determine his ability to complete the task. A progressive loading method was used to determine Mr. Patient's capacity for the performance of dynamic lifting activities on a safe and dependable basis. Lifting was conducted between shoulder height and floor height for a total of 1 repetition at each weight increment. The increase in the amount of weight lifted was in 10-pound increments.
In order to ensure safety in the administration of the testing protocol, Mr. Patient's heart rate was monitored on a real-time basis. A cut-off of 161 beats per minute, based upon 85 percent of the age-predictive maximum heart rate was used in order to ensure the safe administration of the dynamic lifting protocol. A rating of perceived exertion was also used in order to make certain Mr. Patient was capable of continuing in the protocol without risk of injury.
During the course of testing Mr. Patient's heart rate increased from 88 beats per minute to a peak of 98 beats per minute at the final weight of 30 lbs. This represented a heart rate increase of 11% during the lifting protocol. Mr. Patient's heart rate did not recover. Instead it remained constant at 98 beats per minute during the 1 minute recovery period.
Mr. Patient demonstrated a safe weight lifting ability of 30 lbs. The reason for the conclusion of the dynamic lifting protocol was the fact Mr. Patient stopped the test due to psychophysical factors.
0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.00
44
88
132
176
220
Time (min)
Hea
rt R
ate
(BP
M) 88 BPM
98 BPM 98 BPM
98 BPM
Initial Heart Rate:Peak Heart Rate:
Final Testing Heart Rate:
Final RecoveryHeart Rate: 11 %% Heart Rate Increase:
92 BPMAvg. Recovery Heart Rate
01:1601:00
Elapsed Time:Recovery Time:During Testing Before & After Testing
Dynamic Lifting - Floor to Shoulder Occasional
Maximum Allowable HR--
Initial Weight
Starting HeightEnding Height
Shoulder HeightFloor Height10.0 lbs.
Weight Increments 10.0 lbs.Repetitions Per Weight 1 RepetitionRest Period Per Weight Cycle No Rest Period
Exertion Rating Stop PointHeart Rate Cut OffMaximum Test DurationMaximum Allowed Weight
Heavy85% of age adj.UnlimitedNone
Maximum Safe Weight Lifted
May 07, 2009
Patient had difficulty lifting crate to shoulder level during the 30lb cycle. Poking to shoulder and throbbing to lumbar region reported.
Evaluator Comments
P. 11 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
30 lbs.
The Dynamic Lifting - Waist to Shoulder Occasional was conducted in Mr. Patient's case in order to determine his ability to complete the task. A progressive loading method was used to determine Mr. Patient's capacity for the performance of dynamic lifting activities on a safe and dependable basis. Lifting was conducted between waist height and shoulder height for a total of 1 repetition at each weight increment. The increase in the amount of weight lifted was in 10-pound increments.
In order to ensure safety in the administration of the testing protocol, Mr. Patient's heart rate was monitored on a real-time basis. A cut-off of 161 beats per minute, based upon 85 percent of the age-predictive maximum heart rate was used in order to ensure the safe administration of the dynamic lifting protocol. A rating of perceived exertion was also used in order to make certain Mr. Patient was capable of continuing in the protocol without risk of injury.
During the course of testing Mr. Patient's heart rate increased from 88 beats per minute to a peak of 92 beats per minute at the final weight of 30 lbs. This represented a heart rate increase of 5% during the lifting protocol. Mr. Patient's heart rate did not recover. Instead it remained constant at 92 beats per minute during the 1 minute recovery period.
Mr. Patient demonstrated a safe weight lifting ability of 30 lbs. The reason for the conclusion of the dynamic lifting protocol was the fact Mr. Patient stopped the test due to psychophysical factors.
0.0 0.3 0.6 0.9 1.2 1.5 1.8 2.1 2.4 2.7 3.00
44
88
132
176
220
Time (min)
Hea
rt R
ate
(BP
M) 88 BPM
92 BPM 92 BPM
92 BPM
Initial Heart Rate:Peak Heart Rate:
Final Testing Heart Rate:
Final RecoveryHeart Rate: 5 %% Heart Rate Increase:
102 BPMAvg. Recovery Heart Rate
01:5801:00
Elapsed Time:Recovery Time:During Testing Before & After Testing
Dynamic Lifting - Waist to Shoulder Occasional
Maximum Allowable HR--
Initial Weight
Starting HeightEnding Height
Waist HeightShoulder Height10.0 lbs.
Weight Increments 10.0 lbs.Repetitions Per Weight 1 RepetitionRest Period Per Weight Cycle No Rest Period
Exertion Rating Stop PointHeart Rate Cut OffMaximum Test DurationMaximum Allowed Weight
Heavy85% of age adj.UnlimitedNone
Maximum Safe Weight Lifted
May 07, 2009
Patient had a difficult time lifting crate to to shoulder level during the 30lb cycle. Pt reported pain to right shoulder and lumbar following this activity.
Evaluator Comments
P. 12 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
40 lbs.
The Dynamic Carrying was conducted in Mr. Patient's case in order to determine his ability to complete the task. A progressive loading method was used to determine Mr.Patient's capacity for the performance of carrying activities on a safe and dependable basis. Carrying was conducted for a distance of 30 feet during each activity repetition. The lift performed in conjunction with the initiation of the carrying activity was at his waist height level. The programmed increase of the weight in this activity was 10 pounds for each carrying cycle.
In order to ensure safety in the administration of the testing protocol, Mr. Patient's heart rate was monitored on a real-time basis. A cut-off of 161 beats per minute, based upon 85 percent of the age-predictive maximum heart rate was used in order to ensure the safe administration of the dynamic carrying protocol. A rating of perceived exertion was also used in order to make certain Mr. Patient was capable of continuing in the protocol without risk of injury.
During the course of testing Mr. Patient's heart rate increased from 90 beats per minute to a peak of 102 beats per minute at the final weight of 40 lbs. This represented a heart rate increase of 13% during the carrying protocol. Mr. Patient's heart rate did not recover. Instead it remained constant at 102 beats per minute during the 1 minute recovery period.
Mr. Patient demonstrated a safe weight carrying ability of 40 pounds. The reason for the conclusion of the dynamic carrying protocol was the fact Mr. Patient stopped the test due to psychophysical factors.
0.0 0.3 0.6 0.9 1.2 1.5 1.8 2.1 2.4 2.7 3.00
44
88
132
176
220
Time (min)
Hea
rt R
ate
(BP
M) 90 BPM
102 BPM102 BPM
102 BPM
Initial Heart Rate:Peak Heart Rate:
Final Testing Heart Rate:
Final RecoveryHeart Rate: 13 %% Heart Rate Increase:
102 BPMAvg. Recovery Heart Rate
02:1101:00
Elapsed Time:Recovery Time:During Testing Before & After Testing
Dynamic Carrying
Maximum Allowable HR--
Initial Weight
Starting HeightCarry Distance
Waist Height30 Feet10.0 lbs.
Weight Increments 10.0 lbs.Repetitions Per Weight 1 RepetitionRest Period Per Weight Cycle No Rest Period
Exertion Rating Stop PointHeart Rate Cut OffMaximum Test DurationMaximum Allowed Weight
Heavy85% of age adj.UnlimitedNone
Maximum Safe Weight Carried
May 07, 2009
Patient reported an increase in pain levels to lumbar region, from a 4/10 to 5/10 following this activity.Evaluator Comments
P. 13 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
Date May 07, 2009
Please read:This questionnaire has been designed to give the doctor/clinician information as to how your back pain has affected your ability to manage in everyday life. Please answer every section, and mark in each section only the ONE sentence which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the sentence which most closely describes your problem.
Oswestry Low Back Pain Disability Questionnaire
Section 1 - Pain IntensityI can tolerate the pain I have without having to use pain killers.The pain is bad but I manage without taking pain killers.Pain killers give complete relief from pain.Pain killers give moderate relief from pain.Pain killers give very little relief from pain.
Section 2 - Personal Care (Washing, Dressing, etc)I can look after myself normally without causing extra pain.I can look after myself normally but it causes extra pain.It is painful to look after myself and I am slow and careful.I need some help but manage most of my personal care.I need help every day in most aspects of self care.I do not get dressed, wash with difficulty and stay in bed.
Section 3 - LiftingI can lift heavy weights without extra pain.I can lift heavy weights but it gives extra pain.Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, eg. on a table.
Pain prevents me from lifting heavy weights but I can manage light tomedium weights if they are conveniently positioned.
I can lift only very light weights.I cannot lift or carry anything at all.
Section 4 - WalkingPain does not prevent me walking any distance.
Pain prevents me walking more than 1 mile.Pain prevents me walking more than 1/2 mile.Pain prevents me walking more than 1/4 mile.I can only walk using a stick or crutches.I am in bed most of the time and have to crawl to the toilet.
Section 5 - SittingI can sit in any chair as long as I like.I can only sit in my favorite chair as long as I like.
Pain prevents me from sitting more than 1 hour.Pain prevents me from sitting more than 1/2 hour.Pain prevents me from sitting more than 10 mins.Pain prevents me from sitting at all.
Section 6 - StandingI can stand as long as I want without extra pain.I can stand as long as I want but it gives me extra pain.Pain prevents me from standing for more than 1 hour.Pain prevents me from standing more than 30 mins.Pain prevents me from standing more than 10 mins.Pain prevents me from standing at all.
Section 7 - SleepingPain does not prevent me from sleeping well.I can sleep well only by using tablets.Even when I take tablets I have less than six hours sleep.Even when I take tablets I have less than four hours sleep.Even when I take tablets I have less than two hours sleep.
Section 8 - Sex Life
My sex life is normal and causes no extra pain.My sex life is normal but causes some extra pain.My sex life is nearly normal but is very painful.My sex life is severely restricted by pain.My sex life is nearly absent because of pain.Pain prevents any sex life at all.
Section 9 - Social LifeMy social life is normal and gives me no extra pain.My social life is normal but increases the degree of pain.Pain has no significant affect on my social life apart from limitingmy more energetic interests, eg. dancing, etc.
Pain has restricted my social life and I do not go out as often.Pain has restricted my social life to my home.I have no social life because of pain.
Section 10 - Travelling
I can travel anywhere without extra pain.I can travel anywhere but it gives me extra pain.Pain is bad but I manage journeys over two hours.Pain restricts me to journeys of less than one hour.Pain restricts me to short necessary journeys under 30 minutes.Pain prevents me from travelling except to the doctor or hospital.
Pain prevents me from sleeping at all.
Pain killers have no effect on the pain and I do not use them.
Total Score: 25
Disability Percentage Rating 55.56%
Disability Profile Rating: Severe disability
Description: Pain remains the main problem in this group of patients, but travel, personal care, social life, sexual activity and sleep are also affected. These patients require detailed investigation.
P. 14 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
Please read:This questionnaire has been designed to give the doctor information as to how your pain has affected your life. Be sure that these are your answers. Do not ask someone else to fill out the questionnaire for you. Please click on the line in the position that expresses your thoughts from 0 to 100% in each section.
Factor I: 81%Factor II:Factor III: 25%
90%
Factor IV: 55%
Daily Activities Work/Leisure ActivitiesAnxiety/DepressionSocial Interest
No profile match foundPrimary Approach:
Scoring:
Dallas Pain QuestionnaireDallas Pain Questionnaire
To what degree do you rely on pain medications or pain relieving substances for you to be comfortable?
0%( )100%
ALL THE TIMESOMENONE
X*****
SECTION I: PAIN AND INTENSITY
How much does pain interfere with your personal care (getting out of bed, teeth brushing, dressing, etc)?
I CANNOT GET OUT OF BEDSOMENONE (NO PAIN)
X
SECTION II: PERSONAL CARE
How much limitation do you notice in lifting?I CANNOT LIFT
ANYTHINGSOMENONE
(I CAN LIFT AS I DID)
X
SECTION III: LIFTING
Compared to how far you could walk before your injury or back trouble, how much does pain restrict your walking nowI CANNOT
WALKALMOST
THE SAMEI CAN WALK THE SAME
X
SECTION IV: WALKING
Back pain limits my sitting in a chair to:I CANNOT SIT AT ALL
SOMENONE PAIN SAME AS BEFORE
X
SECTION V: SITTING
How much does your pain interfere with your tolerance to stand for long periods?I CANNOT
STANDSOMENONE
SAME AS BEFORE
X
SECTION VI: STANDING
VERY LITTLE
0%( )100%*****
0%( )100%*****
0%( )100%*****
0%( )100%*****
0%( )100%*****
5
3
5
3
4
4
May 07, 2009
P. 15 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
How much does pain interfere with your sleeping?I CANNOT
SLEEP AT ALLSOMENONESAME AS BEFORE
X
SECTION VII: SLEEPING
How much does pain interfere with your social life (dancing, games, going out, eating with friends, etc)?
NO ACTIVITIESTOTAL LOSS
SOMENONESAME AS BEFORE
X
SECTION VIII: SOCIAL LIFE
How much does pain interfere with traveling in a car?
I CANNOT TRAVEL
SOMENONESAME AS BEFORE
X
SECTION IX: TRAVELING
How much control do you feel that you have over demands made on you?
NONESOME(NO CHANGE)TOTAL
X
SECTION XI: ANXIETY/MOOD
How much control do you feel you have over your emotions?
NONESOME(NO CHANGE)TOTAL
X
SECTION XII: EMOTIONAL CONTROL
How depressed have you been since the onset of pain?
OVERWHELMED BY DEPRESSION
NOT DEPRESSEDSIGNIFICANTLY
X
SECTION XIII: DEPRESSION
How much does pain interfere with your job?
I CANNOT WORKSOME
NONE NO INTERFERENCES
X
SECTION X: VOCATIONAL
0%( )100%***
0%( )100%*****
0%( )100%
0%( )100%
* *
**** * *
***** * *
0%( )100%**** * *
0%( )100%***** * *
0%( )100%***** * *
0
1
4
7
5
3
6
P. 16 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
How much do you think your pain has changed your relationships with others?DRASTICALLY
CHANGEDNOT CHANGED
X
SECTION XIV: INTERPERSONAL RELATIONSHIPS
How much support do you need from others to help you during this onset of pain (taking over chores, fixing meals, etc.)?
ALL THE TIMENONE NEEDED
X
SECTION XV: SOCIAL SUPPORT
How much do you think others express irritation, frustration or anger toward you because of your pain?
ALL THE TIMESOMENONE
X
SECTION XVI: PUNISHING RESPONSE
0%( )100%***** * *
0%( )100%***** * *
0%( )100%**** * *
4
2
5
114
May 07, 2009
8988
RestingRate (Min)
Systolic(mm Hg)
Diastolic(mm Hg)
ResultNormal
Heart RateNormal Blood
High Normal Blood Pressure
Cardiovascular Intake
Speed Starting HR Ending HR Comments1.7 88 98 Patient completed this speed with no problem2.5 98 108 Pain to right ankle reported3.4 108 114 Pt reported increased pain to right ankle, pt began using rails and limping. Pt requested testing be stopped.
May 07, 2009
Time (min)VO2
Max (ml kg min ) Percentile Rating
25.94 0% Poor06:34
Bruce TreadmillBruce Treadmill Maximal oxygen consumption is the most valid means of determining cardiorespiratory fitness or maximal aerobic power. Mr. Patient was asked to work on a treadmill in order to directly measure his maximum oxygen intake. The Bruce Treadmill Test (Bruce et al, 1973) is a submaximal test based on the linear relationship that exists between workload (VO2) and heart rate. The test is a continuous, multi-stage test that starts with a low power output and gradually progresses through increments in speed and grade of the treadmill every 3 minutes until the client decides to quit. Mr. Patient's maximum oxygen intake (VO2 max) during the Bruce treadmill protocol was 25.94 ml/(Kg*min) when his maximum oxygen intake is compared to age and sex matched population norms this corresponds to the 0th percentile and is an poor ranking.
The test is a continuous, multi-stage test that starts with a low
speed and grade gradually increasing until the patient
decides to quit. Test Date -1 -1
Evaluator Comment
P. 17 Mr. David Patient
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
Testing Summary Report
Mr. David Patient
Cardiovascular
Time06:34
VO2 Max25.944 0
RatingPoor
Percentile
Bruce Treadmill May 07, 2009
Heart Rate88
Blood Pressure114/89
Cardiovasular Intake May 07, 2009
Range Of Motion
Flexion Contracture:
Plantarflexion40.040.0
100.0%
Dorsiflexion
20.020.0
100.0%
30.030.0
100.0%
Eversion
20.020.0
100.0%
Inversion
Ankle - Left
Total Active MotionNormals
% Normal
May 07, 2009
Flexion Contracture:
Plantarflexion33.040.0
82.0%
Dorsiflexion
20.020.0
100.0%
30.030.0
100.0%
Eversion
16.020.0
80.0%
Inversion
Ankle - Right
Total Active MotionNormals
% Normal
May 07, 2009
Flexion Contracture:
Flexion133.0150.089.0%
Extension
0.00.0
100.0%
Knee - Left
Total Active MotionNormals
% Normal
May 07, 2009
Flexion Contracture:
Flexion117.0150.078.0%
Extension
0.00.0
100.0%
Knee - Right
Total Active MotionNormals
% Normal
May 07, 2009
True Lumbar Flexion
50.02.0%60.0
83.0%
True Lumbar Extension
22.72.0%25.0
91.0%
27.06.0%25.0
108.0%
Right Lateral Flexion
25.00.0%25.0
100.0%
Left Straight Leg Raise35.73.0%80.0
45.0%
Right Straight Leg Raise29.37.0%80.0
37.0%
Left Lateral Flexion
Lumbar
Total Active MotionCo. Of Variation
Normals% Normal
May 07, 2009
Flexion150.0150.0
100.0%
Extension40.040.0
100.0%
150.0150.0
100.0%
Adduction30.030.0
100.0%
Internal Rotation77.080.0
96.0%
External Rotation90.090.0
100.0%
Abduction
Shoulder - Left
Total Active MotionNormals
% Normal
May 07, 2009
All testing was completed using the BTE Technologies System, Data Management was compiled through ODES products of BTE Technologies Inc. P. 1
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
Mr. David Patient
Flexion124.0150.083.0%
Extension32.040.0
80.0%
107.0150.071.0%
Adduction30.030.0
100.0%
Internal Rotation60.080.0
75.0%
External Rotation88.090.0
98.0%
Abduction
Shoulder - Right
Total Active MotionNormals
% Normal
May 07, 2009
Self Reports
I: Daily Activities
81%
II: Work/Leisure Activities
90% 25%
IV: Social Interest
55%
Primary Approach
No profile match found
III: Anxiety/Depression
Dallas Pain Questionnaire May 07, 2009
Score25
Percentile55.56% Severe disability
Rating
Oswestry Low Back Pain Disability May 07, 2009
Strength
Leg Lift56.84.0%
Torso Lift40.1
11.0%
High Near Lift44.79.0%
Arm Lift
Standard NIOSH
ForceCo. Of Variation
May 07, 2009
Work Simulation
Final Safe Weight
40 lbs
Heart Rate Initial
90 102
Final Exertion Rating
08
Termination Reason
Psychophysical factors
Job Demand/Lifting RestrictionNone/None
Heart Rate Maximum
Dynamic Carrying May 07, 2009
Final Safe Weight
30 lbs
Heart Rate Initial
88 98
Final Exertion Rating
07
Termination Reason
Psychophysical factors
Job Demand/Lifting RestrictionNone/None
Heart Rate Maximum
Dynamic Lifting - Floor to Shoulder Occasional May 07, 2009
Final Safe Weight
30 lbs
Heart Rate Initial
90 98
Final Exertion Rating
07
Termination Reason
Psychophysical factors
Job Demand/Lifting RestrictionNone/None
Heart Rate Maximum
Dynamic Lifting - Floor to Waist Occasional May 07, 2009
Final Safe Weight
30 lbs
Heart Rate Initial
88 92
Final Exertion Rating
07
Termination Reason
Psychophysical factors
Job Demand/Lifting RestrictionNone/None
Heart Rate Maximum
Dynamic Lifting - Waist to Shoulder Occasional May 07, 2009
Force Position 144.2 lbs. COV = 5.1%40.0lbs COV = 10.9%
Force Position 252.5 lbs. COV = 2.4%48.3lbs COV = 1.5%
52.2 lbs. COV = 3.3%45.4lbs COV = 5.5%
Force Position 448.9 lbs. COV = 2.4%44.8lbs COV = 2.3%
Force Position 538.2 lbs. COV = 4.7%34.2lbs COV = 6.0%
Force Position 3
Hand Grip - MVE
LeftRight
May 07, 2009
Force47.1 lbs.45.4 lbs.
Hand Grip - Rapid
LeftRight
May 07, 2009
Force26.5 lbs.23.1 lbs.
Normals26.2 lbs.+-5.1 lbs.26.4 lbs.+-4.8 lbs.
NormalNormal
Co. Of Variation10.4%16.1%
Result
Pinch Grip - Key
LeftRight
May 07, 2009
All testing was completed using the BTE Technologies System, Data Management was compiled through ODES products of BTE Technologies Inc. P. 2
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500
Mr. David Patient
Force16.0 lbs.13.4 lbs.
Normals25.4 lbs.+-5.7 lbs.24.7 lbs.+-4.7 lbs.
LowLow
Co. Of Variation22.8%2.7%
Result
Pinch Grip - Palmar
LeftRight
May 07, 2009
Force15.1 lbs.13.0 lbs.
Normals17.6 lbs.+-4.8 lbs.17.6 lbs.+-6.7 lbs.
NormalNormal
Co. Of Variation13.5%3.6%
Result
Pinch Grip - Tip
LeftRight
May 07, 2009
Force60.7 lbs.
Co. Of Variation7.7%
Static Push Strength
Neutral
May 07, 2009
All testing was completed using the BTE Technologies System, Data Management was compiled through ODES products of BTE Technologies Inc. P. 3
REHABILITIES PARTNERS LLC 1208 MCRAE EL PASO TX 79925 915.595.4500